DR. ISE OLUWA AWORINDE MEMORIAL LECTURE 2015.
HEALTH INSURANCE AS A
VEHICLE FOR PROVIDING
QUALITATIVE HEALTH
CARE IN NIGERIA
PREPARED & PRESENTED
BY
DR. ADEYEYE ARIGBABUWO
(MB.BS;MBA;PG.DIP.MARKETING;PG.DIP
.FAMILY MEDICINE; FMSEC; DMP.)
TH
8
@ NECA ON TUESDAY
DEC, 2015
TH
ON THE OCCASION OF HCPAN 11
NATIONAL AGM 2015.
Three clauses are key in this
subject matter
HEALTH INSURANCE
By Health Insurance we mean calculated and
predictable certain amount of cost / money usually
referred to as premium for unpredictable events and
benefits on health packages being a game play and risk
market between the Insurer and the insured.
Insurers are also known as Underwriters . The insured
is known as the beneficiary.
Health insurance is prepaid or pre-purchased usually
by the employer for the benefit of the employee. And
depending on the arrangement, co-payment of cost of
premium may be agreed upon or in some cases the
employer may take absolute responsibility for the
premium.
There are phenomena that are key or
home to health insurance

Premium

Pre-payment
Time
 Risk



Population

Probability

Possibility


Pool


Percentage


Policy

Trust


Capitation
Claims
Accessibility
Affordability
Availability
Acceptability
STAKEHOLDERS:

Purchasers e.g. Government, Corporate Employers, Families,
Individuals, NGOs, Adoption Groups etc.

HMOs (Health Maintenance Organizations): Usually in the middle of
the game as Fund Managers / Corporate Underwriters. May play
dual roles with features of Brokers. When there is good
distinctions, the Brokers may play the role of helping in reinsurance
as well as assisting in claims.

Healthcare Providers: Facilities and Operating Owners. Better to
address facilities rather than Characters or persons or owners.

Roll out of service in relationship with HMOs may address issues of
Network Model; Staff Model or Mixed Model of HMO Care
relationship and structure with Providers.

NHIS (NATIONAL HEALTH INSURANCE SCHEME): As established by Act
35 of 1999. They are the Regulators of Health Insurance and
Managed care in Nigeria .

Enrollees : They form the matrix of end users, and are usually seen
as patients.

Civil Society: They form community policing and serve as social
watchdog.
All these and many more idioms are usual vocabulary we read and
hear about health insurance.
QUALITY
This simply refers to degree of excellence or value.
NIGERIA
A noted country in Africa South of Sahara.
Population: In 2013, the World Bank had put Nigeria's Population
at 173.6 Million. But Worldometres had put the population at
178,516,904 as at 1stJuly 2014. ( Compare the population of 45.2
Million in 1960 ) This population is 2.46% of the World's population.
With a population density of 193 per sq. meter, Nigeria ranks 7th in
the world in terms of population size. The country has one of the
largest population of youth in the world.
It is comparable in size to Venezuela, and about twice the size of
the state of California in the USA. Or the size of California, Nevada,
and Arizona put together. Abuja, now the new capital, replaced
Lagos in December 1991 because of its more central location with
other reasons considered. Lagos still remains the commercial
capital. Other major cities in Nigeria include Ibadan, Kaduna, Kano,
Maiduguri, Jos, Port Harcourt, Enugu, Calabar, Abia, Benin, Aba etc.
Nigeria has over 250 ethnic groups. Nigeria is located in West
Africa and borders the Gulf of Guinea, with Benin on the west and
Cameroun on the east. The average area is 923,768 sq metre (
356,376 sq. miles ) In year 2000. the sex ratio were at 1.02 males to
1,0 females. Life expectancy was 51.58 years for males, and 51.55
years for females.
In planning and epidemiological survey, the real population for Nigeria till
date is very difficult to capture for it is usually tied to representation at the
National Assembly and distribution of the National "cake" The figures are therefore
easily skewed by various groups vying for one political office or the other or for
economic advantage. Where we battle with this till date it is difficult to know how
many people live in Nigeria except by estimate. This has always led to very hot
debates.
Without a very sound knowledge of the Socio-political order as well as
demographic and ethnic structure of the corporate entity called Nigeria , it will be
difficult talking about health insurance driving plan not to talk of quality care .
The 2015 structure of Nigeria is better shared with you visiting :
Nigeria Wikipedia, the free encyclopedia by @UC Browser :
https://en.m.wikipedia.org/wiki/Nigeria.
You are home and dry if you have the basic
features of ban entity you are discussing.
Three types of people have been identified
often:

Those who make things happen

Those who watch things happen

Those who do not even know that things happen around
them
We should not be discussing quality service in a country that
we do not even have an idea of its "quality" structure.
Just a rough guide of a country we are discussing. It is not about
Lagos alone. Not about Port Harcourt or Warri. And neither are we
talking about Maiduguri alone in this case. The country we are
considering is a Big nation with Unity in diversity.

Jamhuriyar Taraiyar Nijeriya.............Hausa

Ohanjiko Ohaneze Naijiriya...................Igbo

Orile-ede Olominira Alaapapo Naijiria.....Yoruba.
Motto: " Unity and Faith, Peace and Progress“.

Capital : Abuja

Largest City : Lagos

Official Languages : English


Major Languages: Hausa; Igbo; Yoruba.
Other Languages: Urhobo-Isoko; Edo; Efik; Fulani; Idoma; Ijaw;
Kanuri; Itsekiri; Igala; Igbira; Nupe; Ibibio; Gwari; Tiv; Birom; Margi;
Jukun ; Katab.
ETHNIC GROUPS:(As at 2014):

Yoruba : 21%

Hausa : 21%

Igbo : 18%

Fulani : 11%

Urhobo-Isoko : 9%

Efik-Ibibio : 7%

Kanuri : 4%

Edo : 3%

Tiv : 2%

Nupe : 2%

Bura : 1%

Others : 8%

Demonym: Nigerian

Government: Federal presidential republic.

President: Muhammadu Buhari

Vice -President: Yemi Osinbajo

Legislature: National Assembly

Upper House: Senate

Lower House: House of Representatives

Independence: From the United Kingdom

Unification of Southern and Northern Nigeria: 1914.

Declared and Recognized: 1st October 1960

Republic Declared: 1st October 1963.

Present Constitution: 29th May 1999.

Area: Total Estimate now: 923,768 sq. km.(356,667 sq. miles.)

Water: 1.4 %

2015 Estimated Population: 182,202,000

2006 Census: 140,431, 790.

GDP (PPP) 2015 estimates:

** Total ..................................$1.109 trillion

***Per Capita ............................$6,204

***GDP ( Nominal) ..........................2015 Estimates

Total ..............................................$573.652billion

*** Per Capita .......................................$3,298

CURRENCY : Naira ( NG#)
HEALTH SYSTEM IN NIGERIA
The NIGERIAN Health System remains a three prong pattern viz:

PRIMARY,

SECONDARY,

TERTIARY.
Health care financing had remained essentially OP (Out of
Pocket) for several decades. In a Corporate way the tradition had
been 'Medical Retainers" form of relationship between the corporate
organizations and organized providers of healthcare delivery.
Also in Nigeria there is preponderance of Private Healthcare
provision in excess of public facilities and care volume. It is
statistically relevant to observe that over 65% of the healthcare of
the nation is provided by the private sector. This is a far cry from a
country like Rwanda where over 90% of the care is of Public Sector
business. It is in this respect I will always want to remind our people
that it is always good to compare apples with apple and never
orange with apple. This background will soon be seen to be very
relevant when we discuss or visit the issue of quality.
We should also bear in mind that the issue of quality is broad and
equally relative.
Quality moving without equity is also synonymous with
discriminations and may be a glorified form of 'apartheid'. However, I
am quick to differentiate between 'equity' and 'equality '. In health
insurance there can never be expectation of equality.
No matter the model and the pattern, especially if we have need
to adopt the American model. While equity will address the issue of
providing according to need equality will preach egalitarianism be it
if need, necessity, or desire. It will simply be shouting 'Equal Rights'.
Yes having access is issue of equal right but having across board
benefit package is issue beyond the sermon of Health Insurance with
''Total and absolute uniform Quality Assurance '. Somebody
somewhere sometime somehow somewhat will always be asking for
'Top ups ' depending on ability, opportunity , and chance of
occurrences.
In America today, and elsewhere users are eager to be on
competitive healthcare provision and consumption, but almost
always expecting the best of care no matter their ability or inability.
Quality is an issue that borders on degree of excellence. It is not
always measured by flamboyant stuff of structural layout or
grandiose of Health personnel. It is not always about big equipment
or highbrow location of facility. More importantly it is a measure of
chain of related tools and inputs that are interested to forecast an
acceptable outcome that seems to say: This is the best '.
For example simple as it may be or sound the waiting time in a
healthcare facility is as important a quality factor as the
qualification of an attending physician. The aggregate of what we
expect as outcome is the integration of the various components that
inform the user if the facility and or practitioner is ideal for care
delivery.
Structure that is converted for use as a healthcare facility will
surely differ in outlay as well as spatial comfort when compared with
a purpose built facility with say a certificate of standard.
When task shifting and task sharing becomes preponderance
compare with appropriate and adequate division of labour, then
there will be differential issue of quality matrix.
HEALTH INSURANCE AS A KEY TO
QUALITY HEALTHCARE
FACTORS THAT HERALD QUALITY CARE FROM
PROVIDERS, HMOs, NHIS, AND ENROLLEE PROVIDERS
Health Insurance formats a direct relationship between providers and
HMOs. In Nigeria this fund Manager pays capitation and claims to the
providers. No need of HR Managers as well as Company Admin
Managers to process bills thereby leading to compromise and
tendency of corruption. The caregiver bow concentrates on
competitive care delivery that ensures quality in all ramifications.
Also prepaid capitations make it possible for facility owners to
preplan for physical development and purchases of commercial
advantage for consumables in hospitals and clinics. Equipment can
either be directly purchased in advance or procured by lease. Property
can also be acquired, renovated or put on merger basis. All these are
good requirement for quality operation. With access to predictable
income the facility becomes more bankable than ever before. This
again is an opportunity to access funds. The ripples effect you have on
this is greater ability to encourage staff training, promotion,
procurement of modern Medicare equipment, etc. All these HERALD
QUALITY.
Also there is a paradox of better dedication and commitment to
duty and greater determination on work plan. For example
subscribers or insured individuals or corporate bodies will only be
prepared to pay for services rendered to them. It is therefore going
to be difficult to want to collect payment for services not rendered
as accountability is better assured in health insurance. The paradox
here is that health workers who go on strike will not expect
ENROLLEE'S or buyers of Health Insurance to agree to pay them for
services not rendered. This is the paradox of quality healthcare on
grounds of assurance of regular access and availability the year
round. Also breach on this direction will bring issue of
accountability which is a necessary requisite to promote litigation.
Consumer charter is thereby ensured and breeds quality
assurance.

Because of autonomy to make free choice of facility by end users,
and opportunity to change a 'non-performing' facility by the end
user, the providers are put on their toes to ensure quality care.

The competitiveness in the open market that promotes perfect
competition in healthcare industry in the era of Health Insurance
opens way to quality care as users will naturally flow to facilities
with structural, administrative, and professional care givers of
excellence.

Providers that are no more exposed threats by Unionized workers
who somewhat encouraged or were partakers on corporate abuse
during Retainership era are now just at liberty to carry out their
professional duty without compromise of joint culpability with
other stakeholders to 'cheat' at any level of care dispensing or
plan . Compromise of quality care just to save cost is no longer
the order of the day.

Working with Regulators, HMOs, as well as other
organized stakeholders will always help HERALD QUALITY.

Facilities that go through accreditation, regulation,
random inspection, and need for data rendition on
regular basis including encounter experiences are all tools
that promote quality care
HMO FACTORS FOR QUALITY
CARE

Appropriate Pricing of Healthcare Delivery (Actuarially Determined
Tariffs)

The Danger of Under Insurance.

Periodicity of capitation as well as claim payment.

Premium vs. Benefit package negotiation with the purchaser of
health insurance in a perfectly competitive market: What is the
minimum acceptable Premium for what benefit package:
Appropriate Pricing of Healthcare service ???

Quality Assurance Department functionality of the HMO.

Criteria for enlisting healthcare facilities on Provider Network List.
Solo practices participation vs. Group practice and ria sharing
Assurance.

" Model of Insurance adopted by the HMO: Staff model, Network
model, Mixed model … Advantages and disadvantages as they
impact on quality.

Capacity building and Skills acquisition/development for staff

Capital base of the HMO and the issue of recapitalization as well
as reinsurance: Solvency issue, distress, and Management
structure of the HMO.

HMO performance bond vs. Provider performance bond Issue of
Indemnity Insurance as it affects quality care.

Vision and Mission statement as they affect the organization core
values with adherence.

Front Desk Officer syndrome: HMO/Provider axis.

ICT: Information / Communication Technology.

Time management and Case Response policy and timeliness

Reward and Sanction policy.

Trust, Transparency, Credibility, pedigree, Reputation, Character,
Culture, and Tradition: Perception and application.

Enforcement of SOP on Providers: STANDARD OPERATIONAL
PROCEDURES.

Minimum number of ENROLLEE to make break even point by both
HMO and PROVIDER.

Need to streamline contents of bundle of benefit package, and
define their matrix of distribution into Primary /capitation and
Claims (fee for service).

Identification of Basic Benefit package vs. Top ups: The quality
outcome of “what money can buy syndrome”.

Benefit derived from harmonization of the various scattered
program.

Community participation and role play in health insurance being
marketed by the HMOs.

Creating a Universal Common Insurance Pool Basket for all forms
of programs to pave way for Quality Health Insurance across
board.

Division of Labour: The need to allow the various professional
groups attend to their various roles and duties in healthcare
delivery for better quality care devoid of unnecessary hospital
economy that may short change the patient. All issues should be
patient centered.

Relationship of HMO with Providers as well as the Regulators
(NHIS) MUST be based on quality assurance without compromise.

International best practices adoption.

Continuous investment on quality will yield quality Consumer,
quality Provider, and yield quality care and quality ENROLLEE. If is
cause and effect.

All other issues are on axis of overlap.
NHIS FACTORS ON QUALITY
CARE DELIVERY
NHIS AS THE HEALTH INSURANCE REGULATOR:

The issue of regulation is key to quality care delivery.

If we adopt the American system, a third party picks the bills and pay.
If we adopt the British system the generality if the people are directly
treated with the Tax of the people.

Where the HMOs are not engaged the issue of religious regulatory
oversight does not exist on this category of Fund Managers. Usually
there have been models with Private Providers Organization.

There have also been instances where independent find Managers are
engaged.

Most parts of the works where the HMOs are engaged they are seen as
interface /mid role player or the Conveyor through which health
insurance can be negotiated for purchase and through which it can be
sublet or deployed to the end users appointing Providers who are care
givers using appropriate business relationship.

Countries like Rwanda and Ghana in Africa do not employ the services
of HMOs. Using then as a prototype study for the NIGERIAN environment
may just be like comparing apple with orange. This same scenario plays
out in the United Kingdom. In all o these countries government
agencies are put in place to do oversight function on monitoring as well
as creating Claims units and departments where providers are paid
after a monthly or quarterly audit of service. Where providers are
overpaid and it appears no response like raising of alarm by the
recipient, then disaster will strike if those charged with whistle blowing
are the first to discover this. It may warrant Sanction or penalty for the
recipient. Fraud detecting mechanism forms a major part of Quality
Assurance of the scheme.

The NHIS is charged by law to undertake the regulatory functions of the
stakeholders in the scheme. This regulatory oversight is supposed to
cover both the Public Health Insurance Scheme as well as the Private
insurance healthcare business. But how much of this regulatory
function is being actively undertaken by the NHIS? Well only recently do
we see some HMOs being sanctioned or punished for flouting the law as
it were. This might be in the true spirit if changing the way we have
been doing our things.

It is key to note that Health Insurance may be of the Social health
Insurance as it applies to a lot of programs by the NHIS or it may be of
PRIVATE health insurance as introduced in the late 90s. Much has been
said about the evolution of health insurance as initiated by the
late Dr. Majekodunmi of blessed memory in 1962. The issue of quality
transcends beyond introduction or evolution of health insurance. It is a
continuum.

The action and / Or inaction of NHIS have a lot to tell on the issue of
quality care and sustainability of the scheme.

**REVIEW OF TARIFF FOR CAPITATION AND FEE FOR SERVICE CLAIMS :

In a couple of African countries where health insurance is practiced,
there is mechanism for periodic review of TARIFF of all sorts of
payments to keep pace with The Time value of money as well as
inflationary trend. In a Nigeria, and since the inception of the Social
health insurance and NHIS unveiling for 10 years and excess, we have
not been able to execute a review of tariff for the scheme. One way or
the other we have blamed unavailability of adequate and regular data
rendition as well as robust encounter data returns. Buy the obvious is
being acted like a drama. It's almost becoming that someone will still
accept if we take Accra to be the Capital of China.

Whether we like it or not the there has been the obvious in virtually all
the sectors of the economy with the downward strength of the naira
over the period if one decade in the case at hand.

The providers only hold the stethoscope, the mortal for compounding
drugs for the Pharmacist, the infra red lamp by the Physiotherapist, the
Nurses watch of Nightingale, the chest market by the Radiographer, the
Test tube by the Lab Scientist. None of us is holding a Crystal ball. The
mystery that surrounds the relatively poor quality healthcare delivery
in Nigeria today does not require the oracles or the forecast of the
crystal ball. Inappropriate pricing of Healthcare, Under insurance, No
responsiveness to the time value of money and inflationary dictates,
delayed or denied payments etc have created an abysmally
unacceptable negative economic balancing for the endangered Provider
who devices survivalist strategies at the very expense of the ethics of
the individual professional groups but to the detriment of the very
patient we are all on oath to serve. This is one big reason quality seems
to be eluding us the more we chase it. Quality is not free. Again it is
not all issues of quality that bothers on money. But if you say the issue
of money is secondary, kindly wait to see what poverty can buy.

** The approach to Universal health coverage should go with the sermon
of quality assurance taking into consideration the socio-cultural belief
and geopolitical order in Nigeria.

Use of appropriate technology is key on managed care. But none the
less, we should all continue to emphasize the minimum quality
standards acceptable to us in this country no matter where the end
user is located or where he/she resides.

** As the slogan now is Universal health coverage, quality becomes the
watch word.
Just as this presenter was a member of the maiden Quality Committee
of the NHIS between 2006 /2010, with no official meeting if the
committee summoned, we do know better now that things are changing
as they have changed.

We must commend the role and action of the NHIS recently in
practicing what they preach concerning issues of regulatory penalty to
any stakeholder trying to undercut or attempting a “smart one”.
SUMMARY OF HEALTH INSURANCE
AND QUALITY EXPECTATION
In summary, thus paper has attempted to broaden our already
ignited knowledge to spark excitement on ACHIEVING QUALITY CARE
THROUGH HEALTH INSURANCE.

(1) NO MATTER WHAT TYPE OF HEALTH INSURANCE, QUALITY SERVICE
IS ONE OF THE CARDINAL FEATURES AS EXPECTED END

(2) WE HAVE PUBLIC SOCIAL HEALTH INSURANCE AND PRIVATE
HEALTH INSURANCE

(3) STAKEHOLDERS DETERMINE THE TYPE AND VALUE OF QUALITY
THEY WANT IN THEIR HEALTH INSURANCE PACKAGES AND PLANS

(4) QUALITY IS IN POLICY, PREMIUM, PLACE, PERSON, PACKAGES,
PERCEPTION, PLAN, TIME, FUNDS, MATERIALS, AND CORE VALUES,
VISION, AND MISSION.
(6) QUALITY IS NOT CHEAP SO NIGERIANS SHOULD NOT TAKE
HEALTH INSURANCE OR MANAGED CARE TO MEAN CHEAP OR POOR
OPTION OF HEALTHCARE FINANCING

(7) UNDER INSURANCE IS A NEIGHBOUR BELOW AVERAGE AND
CAPABLE OF SIMULATING POOR QUALITY HEALTHCARE DELIVERY

(8) TRUST IS A NECESSARY INGREDIENT TO HERALD QUALITY. A
PARTNER WHO OPERATES IN AN ENVIRONMENT WHERE TRUST IS
ERODED IS LEAST CONCERNED ABOUT QUALITY OF SERVICE
RENDERED

(9) GROUP PRACTICE WILL SPREAD RISKS ACROSS STAKEHOLDERS IN
PROVIDERS WORLD M IT SHOULD BE ENCOURAGED

(10) TIMELY PAYMENT OD CAPITATION, FEE FOR SERVICE, AND
APPROPRIATE PRICING OF HEALTHCARE WILL ADDRESS ISSUE OF
GOOD QUALITY EXPECTATION IN HEALTH INSURANCE

(11) DIVISION OF LABOUR WILL MAKE QUALITY EASILY ATTAINABLE
AND SUSTAINABLE. EACH PROFESSIONAL GROUP IN PROVIDER
NETWORK SHOULD RECEIVE PAY DIRECTLY FROM THEIR EMPLOYERS.
GLOBAL CAPITATION DOES NOT FAVOUR QUALITY CARE DELIVERY.

(12) RESPONSIVENESS TO TIME VALUE OF MONEY AND INFLATIONARY
DICATATES HELP ATTAIN AND SUSTAIN QUALITY IN HEALTH INSURANCE

(13) INSURANCE IS A GAME OF NUMBER. A GOOD POOL ON PERSON
AND OTHER RESOURCES IS A PROMISING FUTURE OF GOOD BUSINESS
AND QUALITY ASSURANCE.

(14) FINALLY LET US ADOPT MOTIVATION OF STAFF AND APPRECIATE
PERFORMANCE. IT WILL SURPRISE US HOW SMOOTH WE CAN DRIVE
QUALITY HOME!
Thank you for listening!
PREPARED & PRESENTED
BY
DR. ADEYEYE ARIGBABUWO